The purpose of this research study is to explore the financial, service-related, and partner- related changes that state STD programs have made or plan to make as a result of the changing healthcare environment after passage of the Affordable Care Act. A qualitative approach was employed, using semi-structured interviews of leadership in eight state STD programs to understand their views about key changes that have been made since 2010, and are planned through FY 2016, as a result of the Affordable Care Act and a changing healthcare environment. The researcher was restricted to interviewing no more than one person in nine states due to the limitations imposed by the Paperwork Reduction Act on employees of federal agencies. This Act requires a burdensome, lengthy, and intensive process for approval to collect answers to
questions posed to ten or more persons, which was unfeasible for the purposes of this project. [119] The interviews sought to identify and describe main points in the three key areas of financial changes, service-related changes, and community partner-related changes.
Research Question
This study sought to answer the following question:
What programmatic changes are state sexually transmitted disease programs making as a direct or indirect result of the Patient Protection Affordable Care Act?
Conceptual Model
The Affordable Care Act includes sections that may change the mix of service providers with which states would be anticipated to partner. A change in the insured population and the requirement that private plans cover certain screening services, including many for STDs, in combination with an increased insured population, may also lead states to shift what services they are providing, possibly impacting education, training, sexual partner services, screening, and treatment. Expanded coverage of the population by Medicaid and private insurance could lead federal, state and local governments to expect state and local health departments to bill insurers directly for reimbursement of services provided. To further complicate the situation, state programs are also subject to impact by numerous factors, including: institutionalization of existing programs, community expectations, existing and potential partners, epidemiological factors, economic influences, and political influences. This dissertation did not seek to describe the latter two types, shown with gray boxes in Figure 2. Both of these influences are extremely complex, and could be the subject of additional research.
Figure 2. Conceptual model – influences on state STD program policy and funding.
Qualitative Study Approach
The researcher used a qualitative approach to gather information about the experience of state STD program leadership regarding changes their program has made or plans to make regarding the Affordable Care Act. Since every state program has a different local environment, and programs are likely still in the process of planning or implementing these changes, a survey would not have sufficiently captured the variety of ways in which programs may consider adapting. Additionally, the researcher predicted that these changes could be complex and a fixed set of questions would have been insufficient for capturing this complex information. The
researcher conducted key informant interviews, asking open-ended questions with prompting questions as needed, to solicit information from the participants. The researcher expected that because state programs and their environments vary, they likely approached this differently, and anticipated that each interview would progress dissimilarly. In order to capture the nuances of each state’s approach, the researcher utilized a responsive interviewing approach to flexibly adjust in response to the flow of the interview, the interviewee’s narrative style, and so that the researcher could follow-up on any unanticipated responses.[120]
Institutional Review Board Approval
The researcher requested Institutional Review Board (IRB) approval from the University of North Carolina IRB prior to conducting the research, and was granted approval on September 12, 2013 (Appendix C).
The researcher anticipated that the state environment and other factors specific to the state might be important for understanding the context of the interview responses. Therefore, the researcher filed the IRB request to allow identification of the states, but not the names or roles of the respondents. The researcher surmised that there was a possibility that the participants could be identified by someone using publicly available information, but participation in this study was anticipated to provide minimal risk to the respondents. Answers were related to the person’s occupation, and reflected the actual or planned environment within the state’s STD public health program in relation to an enacted law that has been ruled upon by the Supreme Court.
Selection and Exclusion of Study Participants
As the researcher was interested in the changes being planned and implemented within state STD programs, the researcher wanted to conduct key informant interviews with senior staff in up to nine out of fifty state STD programs that were making changes directly or indirectly related to the ACA. One of the primary decisions was to determine whether to include STD programs in states that had not chosen to expand Medicaid. CDC funded a related project with the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), the National Association of Community Health Centers, Inc. (NACHC), and the National Coalition of STD Directors (NCSD), to engage with several state and local public health programs in order to determine the degree to which public health and health care are integrated related to HIV and STD prevention and services. Interviews and discussions with public health staff, community health center staff, and representatives of primary care associations were conducted in June through August 2013, culminating in an in- person meeting in August 2013. Initial findings were presented at the meeting, during which the investigators reported that they found that only Medicaid expansion states reported making programmatic changes as a result of or in preparation for the full implementation of the ACA. As a result, the researcher chose to exclude all states that had not passed legislation to expand
Medicaid as of July 2013, as reported by the Kaiser Family Foundation. The 27 states that were excluded for this reason were: Alabama, Alaska, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.[121]
2006, completing implementation by 2008.[122] Although the Massachusetts reform had many similarities to national health reform, Massachusetts was at a different point on the continuum for conducting programmatic changes as a result of health reform. In addition, Massachusetts implemented changes without the benefit of the proffered Medicaid expansion with the much higher federal matching rate (100% in the first three years, reduced over time to 90%) that was included in the Affordable Care Act. Furthermore, the economic downturn experienced shortly after Massachusetts’ 2006 health reform was different than the national economic situation after national health reform. Shortly after its health reform, Massachusetts experienced notable budget shortfalls, and made cuts to the STD program, including sudden closure of all STD clinics except one. For these reasons, Massachusetts was anticipated not to be comparable to any other state for the purpose of this study, and was excluded from this study. The researcher did pilot test the interview questions with staff from the Massachusetts program, with the knowledge that despite the reasons for exclusion mentioned above, important lessons or examples might still be gleaned from their experience.
Although insurance expansion has the potential to impact provision and coverage of STD-related services, depending upon the current activities of the state STD prevention program and its budget, some state STD prevention programs may not have made any changes and may not have planned to make any programmatic changes as a result of or anticipation of the Affordable Care Act in the next two years. States without any plans for change within the next three years were also excluded from this study, because the intent was to identify and elucidate the nature of the changes being planned or implemented.
The researcher consulted with CDC STD program staff and reviewed 2012 state STD program annual reports to CDC for the remaining 22 state programs (Arizona, Arkansas,
California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Minnesota, Nevada, New Jersey, New Mexico, New York, North Dakota, Oregon, Rhode Island, Vermont, Washington, West Virginia) in order to determine which state STD programs would most likely make changes because of the ACA. The researcher used this information to target the invitations to participate in the study; the researcher ultimately sent emails to senior staff in sixteen state STD programs to invite them to participate in the study.
Key Informant Interviews
After IRB exemption was obtained, the researcher first pilot tested the interview questions with a representative from Massachusetts over the phone on October 21, 2013, obtaining verbal consent using the approved language (Appendix F). The pilot test provided the type and detail of information the researcher sought without being too lengthy, so the researcher did not make any changes to the semi-structured interview guide (Appendix G). The
Massachusetts pilot confirmed that elimination of all but one STD clinic, due to state budget cuts, was likely the strongest driver for programmatic change, rather than MA health reform or national health reform, validating the decision to exclude that program from this research.
After completion of the interview pilot test, the researcher invited sixteen state STD program staff to participate in the study via an email letter of invitation. This group consisted of responsible professionals, lending credibility to the information the researcher sought to
collect.[120] To recruit key informants, the researcher sent an e-mail to state STD program senior staff that explained the study and asked whether they would be willing to participate in a telephone interview (Appendix D). In addition to inviting participants, the letter identified the purpose of the research project, in order to ensure that only state programs that had made
community partnerships, and finances/budget) were included in the interviews. The email also had attached a copy of the verbal consent (Appendix F).
The researcher followed my initial emails with emails or calls within one to two weeks (Appendix E). For the recipients that indicated via email that they were willing to participate, the researcher followed up with the volunteer to schedule an interview at a time convenient to him or her. Ultimately, staff in eight states either volunteered themselves or shared the email with staff who volunteered. Participating programs included California, Connecticut, Illinois, Iowa, Maryland, Nevada, Oregon, and Washington. All interviews were conducted over the phone between October 31, 2013 and December 4, 2013.
During each phone interview, the researcher first explained the purpose of the study and asked for the informed consent of the volunteers. The researcher walked the participant through the consent form (Appendix F) and obtained their consent, making sure to explain that their answers could be associated with their state in order to tie the responses to other state-specific information, such as STD burden, budget, and other related factors. The researcher also let them know that they could opt out of the interview or choose not to answer questions, although no participants opted to do so. The researcher asked for permission to record the interview, as well as to take notes. The researcher informed them that while the transcript was to be utilized for the study and for programmatic purposes, their responses would not be used by the CDC program to penalize or reward the state. The researcher also stated that no portion of the audio recording would be utilized in an audio format for any purpose, and would be destroyed by the researcher after the study. All volunteers consented and agreed to be voice recorded as permitted under the IRB approval.
The interview questions focused on program and policy changes in three areas: service- related changes, financial changes, and community partner-related changes. The questionnaire guide is included as Appendix F. Questions focused on how state programs were adapting to the changing healthcare environment created by the Affordable Care Act, and how they may have been using this as an opportunity to make programmatic changes, including reaching out to new partners, partnering in new ways with a change in services, or through billing for services by the public health department. If the program was not making changes in a particular area, the
researcher was interested in determining if barriers may have prevented changes from being made, and what technical assistance they thought would be helpful in identifying and/or making changes.
Data Analysis
The researcher digitally recorded each interview. The researcher also took notes during the interview for back-up purposes, and in order to note the highlights of the responses to questions in each of the three areas (financial changes, community partner changes, and service changes), mark progress, and note follow-up questions. The researcher utilized Dragon
NaturallySpeaking 12.0 speech recognition software to assist in creating a written transcription of each digital recording, and then manually checked each transcription against the audio files for accuracy, fixing mistakes made by the software.
The researcher followed Creswell’s general steps for qualitative data analysis, but with additional loops of checking themes and description as the researcher worked through each of the interviews (Figure 3).[123]
Figure 3: Data Analysis Process (Adapted from Creswell)
The researcher reviewed the transcripts and notes, and then coded the data utilizing
ATLAS.ti version 7.1.6, a computer software program designed for qualitative analysis. Analysis was divided into the three main linked areas – financial changes, community partner-related changes, and service-related changes. The researcher identified for each transcript whether specific changes in each of these areas (services, financial, partners) were or were not being made. The researcher also identified barriers, including needs for technical assistance. The researcher also kept a “notable quotes file” as the researcher conducted her analysis, as described in Rubin and Rubin.[120]
Validating the Accuracy of the
Information
Interpreting the Meaning of Themes/Descriptions
Interrelating Themes/Description
Themes Description
Coding the Data (qualitative software)
Read Through Transcripts and Interview Notes
Organizing and Preparing Data for Analysis
Raw Data (transcripts, interview notes) Figure 3: Data Analysis Plan
Figure 4. Interview Codes Used in Atlas.ti
The researcher surmised prior to the study that state context may be relevant to
understanding the participants’ responses.[120] To see if responses were related to context, the researcher looked at two sets of factors. First, the researcher looked at the STD burden and CDC funding level for each of the interviewed programs (Table 3). CDC directly provides funding through a cooperative agreement to all of the states from which a leader was interviewed. In the case of California, San Francisco and Los Angeles are separately directly funded by CDC for STD prevention. Chicago is also funded separately from Illinois, as is Baltimore from Maryland. When looking at these factors, and the analysis of the interview transcripts, the researcher
determined that there was little or no association between these factors and the responses to the questions.
Table 3. Interviewed states and CDC STD state funding, population (ages 15 to 44), and burden of select STDs. State FY2013 CDC STD Funding* 2010 Population Ages 15-44**
Reported Rate per 100,000 Population, 2007-2011 Primary & Secondary Syphilis Gonorrhea Chlamydia California† $5,413,704 11,563,373 4 58.5 380.5 Connecticut $718,672 1,383,547 1.7 71.9 353.1 Illinois‡ $2,070,464 3,997,598 1.8 95.2 352.1 Iowa $727,137 1,177,318 0.7 59.7 322.5 Maryland+ $1,232,806 2,076,687 3.7 74.7 336.5 Nevada $699,354 1,130,438 4.1 75.6 374 Oregon $968,331 1,531,577 1.4 32.3 305.3 Washington $2,438,155 2,765,726 3.2 44.3 320.5 *
Some states also allocate state funds for STD prevention; some counties/cities also allocate funds for STD prevention. Funding information - CDC internal.
**2010 U.S. Census[124] †
excluding San Francisco and Los Angeles ‡
excluding Chicago + excluding Baltimore
Second, the researcher looked at how the eight states included in the study compared in general with respect to several items pertinent to health, utilizing 2013 America’s Health Rankings®. Using the visual distribution of these factors for the eight states (Figure 5), the researcher determined that these states represented a reasonable range across these indicators. From metrics included in America’s Health Rankings ®, the researcher chose overall rank to ensure that a range of state ranks were represented for the most comprehensive indicator for this dataset. The researcher looked at health self-assessment rank as an indicator of perceived health status by state residents, which may be indicative of potential healthcare utilization moving forward. The researcher included public health funding per capita to determine if the states were
the state economic status relative to other states. Overall, the researcher determined that the eight states represented a reasonable cross-section with respect to these indicators, and that these state- specific factors did not appear to be associated with differences in the information collected during the interviews. [125]
Figure 5. Interviewed States and Selected Health Indicators [125]
As a result of the two assessments, the researcher chose not to attribute the responses by state. 0 5 10 15 20 25 30 35 40 45 50 S ta te R a n k
Rank of Interviewed State for Four Health
Indicators
California Connecticut Illinois Iowa Maryland Nevada Oregon Washington Overall State Ranking Self-Reported Health Status Rank Unemployment Rank STATE 1 Public Health Funding per CapitaRank